Baby Deaths Investigations Not Good Enough

Hannah Baty, 6th July, 2016

The BBC has recently reported on an investigation carried out by the Royal College of Obstetricians and Gynaecologists into how problems during labour are investigated. The review concluded that there are too many poor quality investigations into babies who die or are severely brain damaged during labour.

According to the report, more than 900 cases were referred to the programme, and of the 204 investigations, 27% were found to be of poor quality.

The Each Baby Counts inquiry found that ‘In the UK, each year between 500 and 800 babies die or are left with severe brain injury – not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The RCOG does not accept that all of these are unavoidable tragedies, and with the Each Baby Counts project we are committed to reducing this unnecessary suffering and loss of life by 50% by 2020’.

Up until now, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. However, following the inquiry, the Each Baby Counts project team will bring together the results of these local investigations to understand the bigger picture and share the lessons learned. They will collect and analyse data from all UK units to identify lessons learned to improve future care. They will then make recommendations on how to improve practice at a national level.

The medical negligence team at Mayo Wynne Baxter are all too aware that stillbirth, death of a newborn baby or the birth of a baby with brain injuries are life-changing events that significantly affect women and their families. Professor Alan Cameron, vice-president of the Royal College of Obstetricians and Gynaecologists (RCOG) and a consultant obstetrician in Glasgow is of the view that ‘The emotional cost of these events is immeasurable, and each case of disability costs the NHS around £7m in compensation to pay for the complex, lifelong support these children need. Parents’ perspective of what happened is critical to understanding how care can be improved, and they must be given the opportunity to be involved, with open, respectful and sensitive support provided throughout’.

According to the BBC, in 2015, out of 800,000 births after at least 37 weeks of pregnancy, in the UK there were:

655 babies classified as having severe brain injuries

147 neonatal deaths (within seven days of birth)

119 stillbirths

In all cases, the babies had been healthy before labour began.

Professor Alan Cameron comments ‘When the outcome for parents is the devastating loss of a baby or a baby born with a severe brain injury, there can be little justification for the poor quality of reviews found’. Health Minister Ben Gummer states ‘We expect the NHS to review and learn from every tragic case, which is why we are investing in a new system to support staff to do this and help ensure far fewer families have to go through this heartache’.

The BBC interviewed Michelle Hemmington, who sadly lost her son, Louie when he died 35 minutes after being born from hypoxia, due to lack of oxygen. Michelle said ‘It lives with you forever. I think of Louie every day. I’m not the same person I was before he died. There’s always a sadness there – it never goes. Everything is tainted by his death’. Michelle was nine days overdue when she went into labour. She told the BBC that she was left in a hospital bath for two and a half hours because there was no bed for her and told it was "a bad day to have a baby" because it was so busy "I was in labour, but I didn't see anyone for more than five hours…by the time I saw a midwife, my gas and air had run out." Her baby became distressed and his heart rate was monitored, but when a new midwife came on shift, she told Michelle not to panic and did not consult a doctor. When Michelle finally gave birth to Louie, after a further hour and a half's delay, he was taken straight to be resuscitated. Thirty-five minutes later, she was told he had died.

The Each Baby Counts inquiry is hot on the heels of the investigation carried out last year by the University of Leicester, which found that hundreds of hospitals were missing key opportunities to save the lives of hundreds of babies in the UK (see previous blog ‘Learning Lessons and Providing Better Care in Obstetrics’ from November 2015).

At Mayo Wynne Baxter, we have many clients who have found themselves in similar situations to Michelle, and a huge part of their frustration and anger is borne out of a need to know what could have gone so wrong during labour to have such catastrophic consequences. If you have had a similar experience, and feel that the standard of care fell below what it should have done, contact a member of our team on 0800 84 94 101.